Section 1163.473. Hospital utilization review plan

(a) A hospital participating in the MA Program shall have in effect a written utilization review plan approved by Medicare that provides for the review of each recipient’s need for hospital inpatient services. The terms and conditions imposed under the hospital’s utilization review plan for Medicare will, if applicable, apply to MA. If the Medicare utilization review plan is not consistent with this chapter, the Manual for Concurrent Review of Inpatient Hospital Services will take precedence. Those hospitals not participating in Medicare shall submit to the Department’s Bureau of Utilization Review, a utilization review plan which meets the requirements of this chapter.

(b) A hospital utilization review plan shall provide for a utilization review committee that meets the requirements set forth in § 1163.474 (relating to requirements for hospital utilization review committees).

(c) A hospital utilization review plan shall describe the organization, composition and functions of the utilization review committee and shall specify the frequency of the meetings of the committee.

(d) A hospital utilization review plan shall provide that for utilization review purposes each recipient’s record includes:

(1) Identification of the recipient.

(2) Copies of the certification of days records.

(3) The name of the recipient’s physician.

(4) The date of admission and date of application for an authorization of MA benefits if application is made after admission.

(5) The plan of care required under § 1163.476 (relating to plan of care).

(6) Initial and subsequent review dates specified under this chapter.

(7) Reasons and plan for continued stay, if the physician believes continued stay is necessary.

(8) Other supporting material the utilization review committee believes appropriate.

(e) A hospital utilization review plan shall provide for a review of a recipient’s admission to the hospital under § 1163.477 (relating to admission review requirements).

(f) A hospital utilization review plan shall provide for a review of a recipient’s continued stay in the hospital under § 1163.478 (relating to continued stay review requirements).

(g) A hospital utilization review plan shall describe the methods that the utilization review committee uses to select and conduct Medical Care Evaluation studies under § 1163.479 (relating to Medical Care Evaluation studies).

The provisions of this § 1163.472 adopted June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185.

Notation

Cross References

This section cited in 55 Pa. Code § 1163.441 (relating to general participation requirements); 55 Pa. Code § 1163.457 (relating to payment policies relating to out-of-State hospitals); and 55 Pa. Code § 1163.458 (relating to payment policies relating to same-calendar-day admissions and discharges).